Monday, May 18, 2009

Last Thursday, I revealed that the Association for the Treatment of Tobacco Use and Dependence (ATTUD) had issued a press release and written a letter to the FDA requesting that electronic cigarettes be taken off the market, but had not disclosed the financial conflicts of interest of the letter's authors with pharmaceutical companies. Today, I address the substance of ATTUD's argument.

The basic premise of ATTUD's argument is that electronic cigarettes should be "removed from the market until and unless they are proven safe and effective." The authors do not even speculate about how electronic cigarettes may be unsafe. Nor do they address the question of safe compared to what? If you compare inhaling nicotine with inhaling water vapor, of course inhaling nicotine is not going to be safe. But if you compare inhaling nicotine with inhaling tobacco smoke, it's quite a different story.

From a public health perspective, the important consideration is not whether electronic cigarettes have been proven to be safe, but whether there is strong reason to believe that these products are much safer alternatives to cigarettes that are helping many people stay off cigarettes. There is strong evidence that both of the above premises are true: there is little question that electronic cigarettes are much safer than conventional cigarettes and there is abundant evidence that many smokers are using these products successfully to stay off cigarettes.

There also appears to be very strong evidence that the choice for almost all electronic cigarette users is between e-cigarettes and conventional cigarettes, not between e-cigarettes and nicotine abstinence. Thus, if e-cigarettes are removed from the market, smokers will most likely return to conventional cigarettes. So by calling for a ban on electronic cigarettes, what ATTUD is essentially saying is that they would rather that smokers smoke conventional cigarettes with their known, severe hazards, than that they smoke electronic cigarettes which are almost certainly much safer, although they have not been definitively studied in long-term research to prove that they are devoid of any significant adverse effects.

I really find this to be an absurd argument.

But the position being taken by ATTUD is also an inconsistent one.

Consider the following: the drug Chantix is a smoking cessation drug that is suspected of possibly having severe adverse effects, including suicide. That connection has not yet been proven, however. But you don't see ATTUD calling for Chantix to be removed from the market until it has been proven safe.

Why would ATTUD call for the removal of electronic cigarettes from the market, when there is not even a suspicion that they are causing any severe adverse effects, but call for Chantix to remain on the market when there is serious suspicion that it might be causing people to die? This simply makes no sense.

But ATTUD's argument gets even more absurd. They write: "many smokers attempting to reduce or eliminate their cigarette consumption with 'electronic cigarettes' may become frustrated and give up their cessation attempts. A number of smokers will die in the interval between an unsuccessful attempt and a future attempt."

The absurdity of this statement is that smokers who are deprived of electronic cigarettes are almost assuredly going to resume smoking conventional cigarettes. How is it any better to force all electronic cigarette users to return to conventional cigarettes rather than to take a chance that some e-cigarette users will become frustrated and return to regular cigarette smoking? And how do these smokers become more likely to die because they used electronic cigarettes?

The only way this argument would make any sense whatsoever is if the use of electronic cigarettes was preventing smokers who otherwise would have quit entirely from abstaining completely from smoking. However, ATTUD provides no evidence whatsoever that this is the case.

ATTUD goes on to state: "ATTUD's position is to encourage only those attempts (evidence based) with the highest probability of success." But this is an inaccurate statement, because the types of quit attempts with the highest probability of success are cold turkey attempts.

By ATTUD's own logic, due to the dismal effectiveness of nicotine replacement therapy, these products should be removed from the market because many NRT users will become frustrated and return to smoking, giving up their cessation attempts. A number of these smokers will die between their failed quit attempt and a future attempt.

In fact, there is evidence that the use of NRT may be hindering overall quitting because smokers who use these products for an unsuccessful quit attempt may have even more trouble quitting in the future. They may also be less likely to attempt quitting because of a failed attempt using NRT.

If ATTUD were true to its word, it would argue against the use of NRT and other pharmaceutical agents and urge smokers to instead quit with abrupt, cold turkey quit attempts.

Finally, ATTUD argues that e-cigarettes should be taken off the market because children might start using them. This is an uncompelling argument because the same thing is true of over-the-counter nicotine replacement products. If you are going to take a product off the market because children might theoretically get their hands on it and abuse it, then NRT products would have to be removed from the market as well. If anything, children are much less likely to use electronic cigarettes because unlike traditional NRT products, they cost up to $100 and most kids don't have that kind of money sitting around.

There is no question that research on electronic cigarettes and monitoring of the situation is necessary to make sure that there are not unexpected adverse effects and that children are not purchasing these products. There is also legitimate reason to monitor the advertising claims being made. But banning electronic cigarettes is the wrong response. It is not only the worst possible response from a public health perspective, it is also the one with the least evidence to support it.

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About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.